This page allows group members with dental and vision coverages to download our most frequently used forms.

All forms are saved in the .PDF format. To view and print a form requires Adobe Acrobat Reader. You can download a free copy of Reader by clicking here.

If you have any questions about what forms your group uses, contact MedBen Customer Service at 800-686-8425 or medben@medben.com. For technical questions relating to downloading and printing of forms, e-mail this site's webmaster at chuckj@medben.com.

All forms measure 8½”x11” unless otherwise indicated.
Forms open in a new browser window.

MedBen VisionPlus Employer Application
Employers should use this form to apply for group vision coverage under MedBen VisionPlus. (NOTE: If your group is also applying for group health coverage under a MedBen Mutual-sponsored plan, use the MedBen Employer Application instead.)

MedBen Dental Employee Application
New and existing employees of a group covered under MedBen Dental should use this form to apply for dental coverage for themselves and their dependent(s). This form is also used to make changes (name, address) to personal information and add/delete dependents to/from MedBen Dental coverage.
(NOTE: If your group also has group health coverage under a MedBen Mutual-sponsored plan, apply for MedBen Dental coverage using a MedBen Employee Application [8½”x14”], and a MedBen Dental and VisionPlus Change Request Form [8½”x14”] to make changes to dental coverage.)

MedBen VisionPlus Employee Application
New and existing employees of a group covered under MedBen VisionPlus should use this form to apply for vision coverage for themselves and their dependent(s). This form is also used to make changes (name, address) to personal information and add/delete dependents to/from MedBen VisionPlus coverage.
(NOTE: If your group also has group health coverage under a MedBen Mutual-sponsored plan, apply for MedBen VisionPlus coverage using a MedBen Employee Application [8½”x14”], and a MedBen Dental and VisionPlus Change Request Form [8½”x14”] to make changes to vision coverage.)

MedBen Dental and VisionPlus Employee Application
New and existing employees of a group covered under MedBen Dental and/or VisionPlus should use this form to apply for dental/ vision coverage for themselves and their dependent(s). This form is also used to make changes (name, address) to personal information and add/delete dependents to/from MedBen Dental and/or VisionPlus coverage.
(NOTE: If your group also has group health coverage under a MedBen Mutual-sponsored plan, apply for MedBen Dental and/or VisionPlus coverage using a MedBen Employee Application [8½”x14”], and a MedBen Dental and VisionPlus Change Request Form [8½”x14”] to make changes to dental and/or vision coverage.)

Vision Claim Form
Providers can use this form to submit a claim for incurred expenses covered under a MedBen VisionPlus plan. (If you are covered under MedBen VisionPlus, please order a precertified form here.)

Dental Claim Form
Use this form to submit a claim for incurred expenses covered under a MedBen Dental plan.

Notice of Appeal/Designation of Authorization Form
Employees wishing to file an formal appeal of a disputed claim should use this form.  They can also designate another entity to file an appeal on their behalf.

MedBen Mutual Forms • MedBen Administrators Forms
MedBen Specialty Services Forms • MedBen Dental and VisionPlus Forms